Hillel On-Line Student Information Form

 
Title:  First Name*:  Last Name*:

Campus*:   Gender*: Male   Female     Graduation Year*:

School (Local) Address:

Line 1*:
Line 2: 
(Room #/P.O. Box (if applicable))

City*:     

State*:     Zip*:

School Phone # *:   

Cell Phone # :   

Home Address:

Line 1*:
Line 2: 
(Room #/P.O. Box (if applicable))

City*:     

State*:     Zip*:

Home Phone # *:   

Parent Names : 

Email Address*:   

AIM:

Religious Affiliation:        Major:

Interests (check all that apply)
 
AIPAC Jewish Learning
Arts and Culture LGBTQA Issues
Creative Writing Music
Graduate Student Activities Outdoor Programming
Greek Life Shabbat
Holocaust Commemoration Social Action/Justice
Hebrew Speaking Group Social Programming
Israeli Dancing Sports
Interfaith Programming Theatre
Israel Women's Issues

I've been to Israel?: Yes  No

I can lead services/read Torah?: Yes  No

I want a mentor?: Yes  No